(2024) 22:328
Lin et al. BMC Medicine
https://doi.org/10.1186/s12916-024-03538-1

BMC Medicine

RESEARCH

Open AccessInfluences of HPV disease perceptions,vaccine accessibility, and information exposure
on social media on HPV vaccination uptake
among 11,678 mothers with daughters aged
9–17 years in China: a cross‑sectional study
Zian Lin1†, Siyu Chen2†, Lixian Su3†, Yuxue Liao4†, Hongbiao Chen5, Zhiqing Hu6, Zhuolin Chen2, Yuan Fang7,
Xue Liang2, Jianan Chen1, Biyun Luo1, Chuanan Wu1 and Zixin Wang2*

Abstract
Background Mothers play a crucial role in influencing their daughters’ HPV vaccination decisions. Addressing barriers to receiving HPV vaccination among mothers of girls may achieve two goals in one strike: increasing vaccination
coverage among both mothers and their daughters. This study aims to examine the HPV vaccination uptake and its
determinants among mothers of girls in China at both the individual and interpersonal levels.
Methods From July to October 2023, a cross-sectional online study was conducted to investigate HPV vaccine
refusal for daughters aged 9–17 years among 11,678 mothers in Shenzhen, China. A randomized selection method
was employed, targeting 11 primary schools and 13 secondary schools in Shenzhen. The research team invited mothers of girls to participate in an anonymous online survey. Multilevel logistic regression models (level 1: schools; level 2:
individual participants) were employed to analyze the data.
Results Among 11,678 mothers, 41.1% self-reported receiving at least one dose of HPV vaccination. Through multilevel logistic regression analysis, eight items measuring illness representations of HPV, which refers to how people
think about HPV, were associated with higher HPV vaccination uptake (AOR: 1.02–1.14). These items included identity(identifying symptoms of HPV), timeline (whether HPV is acute/chronic), negative consequences, personal and treatment control (whether HPV is under volitional control), concern, negative emotions, and coherence (overall understanding of HPV). In addition, participants refusing HPV vaccines for the index daughters (AOR: 0.82, 95%CI: 0.76, 0.89)
had lower vaccine uptake. Perceived more difficulties in accessing the 9-valent vaccines (AOR: 1.06, 95%CI: 1.04, 1.08)†

Zian Lin, Siyu Chen, Lixian Su and Yuxue Liao contributed equally to thismanuscript.

†

Zian Lin, Siyu Chen, Lixian Su and Yuxue Liao share the first authorship.

*Correspondence:
Zixin Wangwangzx@cuhk.edu.hk
2Centre for Health Behaviours Research, JC School of Public Healthand Primary Care, Faculty of Medicine, The Chinese University of Hong
Kong, Hong Kong SAR, China
Full list of author information is available at the end of the article© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0
International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as longas you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article orparts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicatedotherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To
view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.

Lin et al. BMC Medicine(2024) 22:328

Page 2 of 14

and more satisfaction with vaccine-related promotional materials (AOR: 1.50, 95%CI: 1.46, 1.54) at the individual level
were associated with higher vaccine uptake. At the interpersonal factors, higher frequency of exposure to testimonials given by others about HPV vaccination on social media (AOR: 1.19, 95%CI: 1.14, 1.25) and thoughtful considerationof the veracity of the information (AOR: 1.11, 95%CI: 1.07, 1.16) were correlated with higher HPV vaccination uptake.
Conclusions These findings offer essential implications for modifying HPV disease perceptions, addressing difficulties
in accessing the 9-valent HPV vaccines, and enhancing health communication needs to improve HPV vaccine uptake
among mothers of girls.
Keywords HPV vaccine uptake, Mothers of girls, Illness representation, Satisfaction with health promotion materials,
Social media influence, Socioecological model, China

Background
Cancers caused by human papillomavirus (HPV) are serious
health threats for women. Globally, about 625,600 womenare diagnosed with HPV-related cancers annually [1]. Boththe incidence and mortality rate of HPV-related cancers arehigh and increasing continuously among Chinese women[2–4]. HPV vaccination is highly effective in preventing
HPV-related cancers without safety concerns [5, 6]. Receiving HPV vaccination prior to the onset of sexual behaviors was considered the most efficacious [7–9]. The main
scheme of the HPV vaccination program in China started
to roll out in 2016. The main scheme first provided bivalent HPV vaccines to females aged 9–45 years (in August2016) [10], and then expanded to supply quadrivalent andthe 9-valent vaccines to the same age group of females in
May 2017 [10] and August 2022 [11]. Although the basic
health insurance in China covers 80% of the cost of bivalent(¥1080 or US$148 for the whole course) and quadrivalentvaccines (¥2496 or US$343 for the whole course), it cannot cover the 9-valent vaccines (¥3993 or US$547 for thewhole course). A pilot scheme under the national program
started in 2022 in some Chinese cities including Shenzhen,
the study site, providing free bivalent vaccines to girls aged
13–15 years. However, girls who wish to receive quadrivalent or the 9-valent vaccines have to follow the arrangementof the main scheme. Currently in China, HPV vaccination
is not available for males. In China, the mean age at sexual
debut for girls ranges from 19.3 to 23.1 years [12, 13]. The
coverage of at least one dose of HPV vaccination in different
age groups of females was 4.6% (9–17 years), 23.4% (18–26
years), 22.0% (27–35 years), 20.2% (36–44 years), and 3.2%
(45–50 years), respectively [14].
Mothers have an important influence on their daughters’
HPV vaccination uptake. In China, mothers are the main
decision-makers for their children’s vaccination [15]. Previous studies highlighted the important roles of mothersin communicating with their daughters about vaccination,
reproductive health, and sexual behaviors [16, 17]. In theliterature, mothers who were hesitant to receive HPV vaccination were unlikely to vaccinate their daughters against
HPV [18–22]. In China, most mothers with daughters

aged 9–17 years are within the recommended age limit (45years) for HPV vaccination. Addressing barriers to receiving HPV vaccination among this group of mothers mayachieve two goals in one strike (i.e., increasing vaccination
coverage among both mothers and their daughters).
Determinants to receive an HPV vaccination among
women in general and girls under 18 years in China were
well studied. However, very few studies examined the facilitators and barriers to receiving an HPV vaccination among
the group of mothers with daughters aged 9–17 years. Ourliterature identified three relevant studies, which showedthat the HPV vaccination uptake rate was between 2.6 and18.6% among Chinese mothers having daughters [23–25]. A
limited number of determinants were considered by thesestudies, such as background characteristics (i.e., the level of
education and income, history of HPV infection), daughter’sage, and perceptions regarding HPV vaccination (i.e., concerns about protection and costs, availability issues, family
recommendations, and perceived self-efficacy) [23–25].
This study examined the determinants of HPV vaccination uptake among mothers at both the individual andinterpersonal levels under the socioecological model [26],a commonly used framework to understand facilitatorsand barriers of vaccination uptake [27–31]. At the individual level, this study considered illness representations
using the Brief Illness Perception Questionnaire (B-IPQ)
and satisfaction with governmental health promotion
materials. Illness representations refer to how individuals
think about a disease or health condition [32], which has
been increasingly used to explain various health behaviors and outcomes [33–35]. The Common-sense Model of
Self-regulation suggests that individuals would constructschematic representations of an illness based on available
information [32]. A health threat (i.e., HPV infection)
would activate cognitive representation to regular theobjective threat and the emotional representation to regulate emotions [36]. Both types of illness representations
would guide the coping strategies for the health threat.
Illness representations have been applied to understanddeterminants of various types of vaccination (i.e., coronavirus disease 2019 (COVID-19), pneumococcal, andLin et al. BMC Medicine(2024) 22:328

mpox vaccination) [33–35]. Health authorities in China
have been promoting HPV vaccination through different mass media channels. It is crucial to assess the levelof satisfaction among mothers regarding these healthpromotion materials, as they may not comprehensively
address mothers’ concerns or provide adequate information to facilitate the decision-making process for vaccination [3, 37]. Previous studies showed that people who
were more satisfied with the government-produced vaccination materials had a higher uptake rate of COVID-19
vaccination [38, 39]. As compared to bivalent and quadrivalent HPV vaccines, the 9-valent HPV vaccines offer
more comprehensive protection against HPV [40]. Previous studies suggested that Chinese women preferred
to receive the 9-valent HPV vaccines over other typesof vaccines [41, 42]. However, local news reported someissues related to the accessibility of the 9-valent HPV vaccines. Since the supply of 9-valent HPV vaccines could
not meet its demands, most Chinese cities set limited
quotas for receiving such vaccine [3]. Moreover, the procedures to register for the 9-valent vaccines were considered complicated [43]. The cost of the 9-valent vaccines
may be another issue, as it is high and cannot be coveredby basic health insurance in China (¥3993 or US$547 forthree doses) [44]. Thus, the accessibility of the 9-valent
HPV vaccines could potentially influence a mother’sdecision to receive HPV vaccination.
At the interpersonal level, social media platforms are
crucial and indispensable health-related information
sources. In the context of HPV vaccination, Chinese
mothers heavily rely on social media to gather information about vaccination [45]. Exposure to negative or
anti-vaccine content on social media was associated withlower uptake of HPV vaccination [45]. In contrast, exposure to information supporting vaccination uptake could
reduce vaccine hesitancy [46]. In addition, misinformation related to vaccination is widespread on social media,
which may aggravate vaccine hesitancy [47, 48]. Thoughtful consideration of the veracity of the information onsocial media could help mitigate the negative impact of
misinformation [49, 50]. Previous studies showed a significant positive correlation between thoughtful consideration and vaccination uptake [50, 51]. Therefore, thisstudy also investigated the associations between theseinterpersonal-level factors and HPV vaccination uptake
among mothers with daughters aged 9–17 years.
To our knowledge, there was a dearth of studies
investigating the influences of HPV disease perceptions, accessibility of the 9-valent vaccines, satisfaction
with governmental promotional materials, or social
media information exposure on the HPV vaccination
uptake among Chinese mothers having daughters. To
address the knowledge gaps, this study investigated HPVPage 3 of 14

vaccination uptake among mothers with daughters aged
9–17 years in Shenzhen, China. We also examined potential determinants of vaccination uptake at the individuallevel (HPV vaccine refusal for daughters, illness representation of HPV, satisfaction with governmental health promotional materials, and accessibility of the 9-valent HPV
vaccines) and interpersonal level (information exposure
on social media and thoughtful consideration of veracityof information). We hypothesized that mothers’ establishing specific perceptions about HPV influenced subsequent vaccination behavior and that satisfaction withgovernmental health promotional materials, accessibility of the 9-valent vaccines, and information exposure onsocial media would significantly impact their HPV vaccination uptake.

Methods
Study design

A cross-sectional online survey was conducted to investigate HPV vaccine refusal for daughters aged 9–17
years among mothers in Shenzhen, China, between Julyand October 2023 [52]. This study is a secondary analysis among mothers aged 52 years or below. We did notinclude mothers aged over 52 years (45 years in 2016), as
they were unlikely to benefit from the main scheme of thenational HPV vaccination program (started in 2016 forwomen aged 9–45 years).
Participants and data collection

The inclusion criteria for the original study were as follows: (1) mothers aged 18 or above, (2) able to read simplified Chinese, (3) having a daughter aged between 9 and17 years at the time of the survey, (4) the daughter wasattending a primary or secondary school in Shenzhen,
and (5) having a smartphone with internet access.
Our research team randomly selected 3% of the primary and secondary schools from the updated school
list in Shenzhen (11 out of 343 primary schools and 13
out of 475 secondary schools) using Excel’s “select random cells” function. All these schools agreed to participate. These schools have established WeChat groups forparents and teachers to communicate school notices.
Teachers in the selected schools posted the study information and a QR code to access the questionnaire in the
WeChat groups, inviting mothers of female students toparticipate. The teachers also sent reminders twice during the study period in the WeChat groups. Participants
were asked to keep the survey link private from people
outside the WeChat groups. Before starting the online
survey, participants were informed that participation was
voluntary and their personal information would be kept
confidential. Electronic informed consent was obtained.
The research team developed an online questionnaire

Lin et al. BMC Medicine(2024) 22:328

using Questionnaire Star, a widely used survey platform
in China. The questionnaire consisted of 90 items, with
about 15 items per page for six pages, which took about
15 min to complete. The online survey platform checked
for completeness before submission, allowing participants to review and change their responses. No incentives were given to participants. The data, protected by apassword, was stored on the survey platform server, with
only the corresponding author accessing the database.
During the study period, 11,728 mothers completed thesurvey (response rate: 83.8%). We excluded 50 participants aged over 52 years and performed analysis among
the remaining 11,678 participants. Ethics approval was
obtained from the Shenzhen Longhua District Maternity
and Child Healthcare Hospital (ref: 2022122201).
Sample size planning

Sample size planning of the original survey was explainedin a published paper [52]. This secondary analysis
included 11,678 participants. Such sample size allowed us
to detect the smallest odds ratio of 1.12 between motherswith and without the facilitating conditions, with a powerof 0.80 and an alpha of 0.05 and assuming the HPV vaccination uptake rate in the reference group (with a facilitating condition of HPV vaccination) to be 10–50% (PASS
11.0, NCSS LLC).
Measurements
Development of the questionnaire

The study questionnaire was designed by a panel ofexperts, including epidemiologists, clinicians, and CDC
employees. To ensure its clarity and readability, the questionnaire underwent a pilot test with ten mothers. All
participants in the pilot study found the questionnaireeasy to understand. Using their feedback, the panel madefinal adjustments to the questionnaire. These ten mothers
were not involved in the actual survey.
Covariates: background characteristics

The questionnaire gathers sociodemographic information
about mothers, including age, education level, relationship status, employment status, and monthly householdincome. Information about their self-reported history of
HPV-related diseases and the age of their daughters was
also collected.
Dependent variable: HPV vaccination uptake among mothers

Mothers provided information on the number of HPV
vaccine doses they received. Additional details on the

Page 4 of 14

type and location of vaccination were collected for those
who had received at least one dose.
Independent variables at the individual level

In case the participant has more than one daughter aged
9–17 years, she referred to the one whose birthday isclosest to the survey date when answering the questions. Participants were first asked whether their index
daughters had received any HPV vaccination. For mothers whose index daughters had not received any HPV
vaccination, they were asked about their likelihood of
having the index daughters received HPV vaccination in
the next year (response categories: 1 = very unlikely, 2= unlikely, 3 = neutral, 4 = likely, and 5 = very likely).
Vaccine refusal was defined as “very unlikely,” “unlikely,”or “neutral.” The same definition was used in numerous
studies [52, 53].
Participants’ illness representations of HPV wereassessed using the B-IPQ [54]. This reliable and valid
approach was commonly used in previous studies toevaluate illness representations of individuals at risk fora particular disease [54, 55]. In this study, the B-IPQ
scale was modified by replacing “illness” with “HPV”[54]. The open-ended question about the cause of illness
was not included, consistent with previous research [54].
The remaining eight B-IPQ items assessed scores ranging from 0 to 10. These items include (1) consequences(“If you contracted HPV, how much does HPV infection
affect your life?”), (2) timeline (“If you contracted HPV,
how long do you think your illness will continue?”), (3)personal control (“If you contracted HPV, how muchcontrol do you feel you can deal with the illness?”), (4)treatment control (“If you contracted HPV, how much do
you think existing treatment can help your illness?”), (5)identity (“If you contracted HPV, how much do you experience symptoms from the illness?”), (6) concern (“If you
contracted HPV, how concerned are you about your illness?”), (7) coherence (“If you contracted HPV, how well
do you feel you understand HPV?”), and (8) emotions (“Ifyou contacted HPV, how much does your illness affectyou emotionally?”) [36]. Higher scores on consequence,
timeline, identity, concern, and emotion items indicatedmore negative perceptions of the illness, while higherscores on personal control, treatment control, and coherence indicated more positive perceptions.
We modified the scale validated in the Chinese population to measure satisfaction with government-produced
HPV vaccination health promotional materials (i.e.,
advertisements, posters, and others) [56]. The Cronbach’s
alpha for this scale was 0.91. Participants were asked
whether the information presented by the health promotional materials was helpful for them to understandthe policy and arrangement of HPV vaccination, address

Lin et al. BMC Medicine(2024) 22:328

Page 5 of 14

concerns related to HPV vaccination, and facilitate theirdecision to receive an HPV vaccination (response categories: 1 = disagree, 2 = neutral, 3 = agree). Higher scoreson the scale indicated higher satisfaction with the healthpromotional materials.
Four items measured perceived accessibility of the
9-valent HPV vaccines; they were (1) “It’s difficult toobtain a quota to receive the 9-valent vaccines online,” (2)“Making an appointment to receive the 9-valent vaccine
is complicated,” (3) “There is an insufficient supply of the
9-valent vaccines,” and (4) “The cost is expensive for the
9-valent vaccines” (response categories: 1 = disagree, 2 =neutral, 3 = agree). The Difficulties to Access the 9-valent
Vaccine Scale was constructed by summing up individual
item scores, with higher scores indicating lower accessibility of the 9-valent vaccines. The Cronbach’s alpha forthis scale was 0.82.

showed significance at P < 0.05 in the univariate analysis were then included and adjusted in the multivariate
two-level logistic regression model. Crude odds ratio(OR), adjusted odds ratios (AOR), and their 95% confidence intervals (CI) were reported. Multicollinearities
were assessed through the variance inflation factor (VIF);
variables exceeding a VIF value of 5 were adjusted oreliminated if theoretically redundant. Hosmer and Lemeshow goodness-of-fit test was used to assess model fits oflogistic regression models. The insignificant Hosmer andLemeshow goodness-of-fit test (P > 0.05) indicates thatthe model’s estimates fit the data at an acceptable level[60, 61]. The analyses were performed using SPSS (version 29.0; IBM, Armonk, NY, USA). A significance levelof P < 0.05 was used.

Independent variables at the interpersonal level

About half of the participants were aged between 36 and40 years (41.6%), had received tertiary education (48.2%),
and were without a full-time job (58.3%). The majorityof them were married (95.9%), had a monthly householdincome of more than ¥5000 (USD 685) (83.4%), and did
not have a history of HPV infection (95.9%) or HPVrelated diseases (97.8%). Over half of them had a daughter who was 9–12 years old (61.1%) (Table 1).

We adapted validated questions to assess the frequencyof exposure to information related to HPV vaccination oncommon social media platforms in China (i.e., WeChat
moments, Weibo, TikTok, Red) in the past month [57].
These questions included exposure to testimonials fromothers, dissemination of negative information pertaining
to HPV vaccines, and dissemination of negative information related to other vaccine incidents in China. Anothervalidated measurement was used to measure thoughtfulconsideration about the veracity of information specificto HPV vaccines [49]. The response categories to thequestions above were 1 = almost none, 2 = seldom, 3 =sometimes, and 4 = always.
Statistical analysis

Descriptive statistics were presented. The mean andstandard deviation (SD) of the items and scales measuring satisfaction with health promotional materials,
accessibility of the 9-valent vaccines, illness representation, and influence of social media related to HPV or
HPV vaccinations were also calculated. The dependent
variable was the uptake of at least one dose of the HPV
vaccine among mothers. Multilevel logistic regression
models (level 1: schools; level 2: individual participants)
were employed to investigate the factors related to thedependent variable. Random intercept models were utilized to accommodate the variance in the regression
model’s intercept across schools, addressing the issue of
intra-correlated nested data. This approach is frequently
used in previous studies employing similar sampling
methods [58, 59]. A univariate two-level logistic regression model was used to evaluate the significance of therelationship between each background characteristic andthe dependent variable. Background characteristics that

Results
Background characteristics

HPV vaccination uptake

Among all participants, 41.1% (n = 4800) self-reported
receiving at least one dose of HPV vaccination, and 64.9%
of vaccinated participants (3115/4800) completed thewhole course of vaccination. Among vaccinated participants, 53.0% received a quadrivalent vaccine (Gardasil 4)(2547/4800), 18.1% received the 9-valent vaccines (Gardasil 9) (868/4800), 15.2% received a bivalent vaccine(729/4800), and 13.7% were uncertain about the type of
vaccine they received (656/4800). The most common
venues to receive HPV vaccination were public hospitals
and community health centers in Shenzhen (3935/4800,
82.0%) (Table 2).
HPV vaccine refusal for daughters

Among the mothers, 18.2% reported that their 9–17
years old daughters had taken up HPV vaccines. Among
participants whose 9–17 years old daughters were unvaccinated against HPV, 46.7% intended to have such daughters received HPV vaccination in the next 12 months. The
proportion of mothers who had HPV vaccine refusal for
their 9–17 years old daughters was 43.3% (Table 2).
Other factors at individual and interpersonal levels

The mean scores and SD of the items related to illness representations of HPV were presented in Table 2.

Lin et al. BMC Medicine(2024) 22:328

Page 6 of 14

Factors associated with HPV vaccination uptake

Table 1 Background characteristics of the participants (n =11,678)
n

%

18–35

3175

27.2

36–40

4863

41.6

41–52

3640

31.2

Junior high or below

3304

28.3

Senior high or equivalent

2741

23.5

College and above

5633

48.2

Age group, years

Education level

Relationship status
Married11,194 95.9

Currently single

484

4.1

Full time

4872

41.7

Without full-time job

6806

58.3

<5000 (685)

1944

16.6

5000–9999 (685–1369)

3551

30.4

10,000–15,000 (1369–2054)

1902

16.3

>15,000 (2054)

3110

26.6

Refuse to disclose

1171

10.0

Employment status

Monthly household income, ¥ (US$)

Self-reported history of HPV infection
No

11,199 95.9

Yes

479

4.1

Self-reported history of HPV-related diseases (i.e., genital warts, cervical/
anus/vagina cancers, and precancerous lesions)No

11,420 97.8

Yes

258

2.2

9–12

7132

61.1

13–17

4546

38.9

Age of the index daughter, years

More than half of the participants found it challenging toobtain the 9-valent vaccines (Gardasil 9) quota (60.5%)
and considered the cost of these vaccines to be expensive(64.8%). Less than half of the participants were satisfied
with government-produced promotional materials for
HPV vaccination (39.1–42.8%).
Regarding the interpersonal-level variables, less than
30% of participants were sometimes/always exposed
to testimonials given by others about HPV vaccination(29.2%), negative information (27.8%), and other vaccine
incidents related to HPV vaccination (25.8%) on commonsocial media platforms. About 16.3% of the participants
always considered the veracity of HPV vaccine-specificinformation (Table 2).

In the univariate analysis, mothers who were older, currently single, with an older daughter, and without fulltime jobs were less likely to take up HPV vaccination.
Higher education, higher income, and a history of HPV
infection or disease were correlated with higher HPV
vaccination uptake (Table 3).
After adjusting for significant background characteristics, HPV vaccines refusal for their index daughters wascorrelated with lower HPV vaccination uptake among
mothers (AOR: 0.82, 95%CI: 0.76, 0.89). Participants who
perceived more negative effects of HPV on their lives(consequences) (AOR: 1.02, 95%CI: 1.00, 1.03), longer
duration of HPV infection (timeline) (AOR: 1.02, 95%CI:
1.00, 1.03), HPV infection can be controlled by themselves (personal control) (AOR: 1.05, 95%CI: 1.04, 1.06)
and medical treatment (treatment control) (AOR: 1.04,
95%CI: 1.02, 1.05), severe symptoms if contracted HPV(identity) (AOR: 1.05, 95%CI: 1.03, 1.07), more concerns(concern) (AOR: 1.14, 95%CI: 1.12, 1.15) and better
understanding of HPV (coherence) (AOR: 1.13, 95%CI:
1.11, 1.15), and negative emotional responses to HPV(emotions) (AOR: 1.06, 95%CI: 1.05, 1.07) had higher
HPV vaccination uptake. More satisfaction with thegovernment’s health promotional materials (AOR: 1.50,
95%CI: 1.46, 1.54) and perceived more difficulties (AOR:
1.06, 95%CI: 1.04, 1.08) in accessing the 9-valent HPV
vaccines were also associated with higher HPV vaccination uptake. At the interpersonal level, a higher frequencyof exposure to testimonials given by others about HPV
vaccination (AOR: 1.19, 95%CI: 1.14, 1.25) was associatedwith higher vaccine uptake. Thoughtful consideration of
the veracity of the information specific to HPV vaccines
was also associated with higher vaccine uptake (AOR:
1.11, 95%CI: 1.07, 1.16) (Table 4). The VIF values for eachvariable in all logistic models were consistently below 5,
ranging between 1.00 and 1.21, indicating that no adjustments were necessary for the variables. The aforementioned logistic regression models had acceptable fits
(Hosmer and Lemeshow test ranged from 0.07 to 0.94).

Discussion
To our knowledge, this is one of the first studies toinvestigate the influence of HPV disease perceptions,accessibility of the 9-valent vaccines, satisfaction withgovernmental health promotional materials, and social
media information exposure on HPV vaccination uptake
among mothers having daughters. This study included
the novel application of the Common-sense Model of
Self-regulation to examine HPV disease perceptions,which extended the application of this theory and could
inform public health messaging that is theoreticallyLin et al. BMC Medicine(2024) 22:328

Page 7 of 14

Table 2 HPV vaccine uptake, individual level and interpersonal level factors related to HPV and/or HPV vaccines (n = 11,678)n%

HPV vaccine uptake
Uptake of at least one dose of HPV vaccine
  No

6878

58.9

  Yes

4800

41.1

Number doses of HPV vaccination completed by the participants (among 4800 participants who had received at least one dose of HPV vaccine)   One dose of domestic bivalent vaccines

40

0.8

   Two doses of domestic bivalent vaccines

506

10.5

   One dose of imported bivalent vaccines

11

0.2

   Two doses of imported bivalent vaccines

146

3.1

   One dose of quadrivalent vaccine (Gardasil 4)

75

1.6

   Two doses of quadrivalent vaccine (Gardasil 4)

346

7.2

   Three doses of quadrivalent vaccine (Gardasil 4)

2098

43.7

   One dose of 9-valent vaccine (Gardasil 9)

203

4.2

   Two doses of 9-valent vaccine (Gardasil 9)

294

6.1

   Three doses 9-valent vaccine (Gardasil 9)

365

7.6

  Uncertain

716

15.0

Type of HPV vaccination received by the participants (among 4800 participants who had received at least one dose of HPV vaccine)   Domestic bivalent vaccines

567

11.8

   Imported bivalent vaccines

162

3.4

   Quadrivalent vaccine (Gardasil 4)

2547

53.0

   9-valent vaccine (Gardasil 9)

868

18.1

  Uncertain

656

13.7

Venues of HPV vaccination uptake among the participants (among 4800 participants who had received at least one dose of HPV vaccine)   Public hospitals or community health centers in Shenzhen

3935

82.0

   Private hospitals in Shenzhen

437

9.1

   Other provinces or cities

156

3.3

   Hong Kong, Macao, or other countries

425

8.9

Individual level factors
HPV vaccine refusal for index daughters
The index daughters have received HPV vaccines
  No

9482

81.8

  Yes

2196

18.2

Likelihood of having the index daughter take up HPV vaccines in the next 12 months (among mothers whose index daughters have never received any HPV vaccines, n= 9482)   Very unlikely/unlikely/neutral

5055

53.3

  Likely/very likely

4427

46.7

HPV vaccine refusal for their daughters
  No

6623

56.7

  Yes

5055

43.3

  ­
Consequencesa

7.2

3.2

  ­Timelineb

6.9

3.0

  Personal ­controlc

5.5

3.1   Treatment ­controld

6.2

2.8

  ­
Identitye

7.9

2.6

  ­
Concernf

7.7

2.7

  ­
Coherenceg

4.8

2.7

  ­
Emotionsh

7.0

2.9

Domains of the Brief Illness Perception Questionnaire (B-IPQ), mean (SD)Satisfaction with HPV vaccine health promotional materials (i.e., advertisement, poster, and others) produced by the government, yes   Helpful for you to understand the policy and arrangement of HPV vaccination

5000

42.8

   Can address your concerns related to HPV vaccination

4570

39.1

vHelpful for you to make decision on whether to receive HPV vaccines   Satisfaction with Health Promotional Materials ­Scalei, mean (SD)

4938

42.3

7.1

1.6

Lin et al. BMC Medicine(2024) 22:328

Page 8 of 14

Table 2 (continued)
n%Difficulties to access the 9-valent HPV vaccines, agree   It’s difficult to obtain a quota to receive the 9-valent vaccines (Gardasil 9) online

7067

60.5

   Making an appointment to receive the 9-valent vaccines (Gardasil 9) is complicated

5331

45.6

   There is an insufficient supply of the 9-valent vaccines (Gardasil 9)

6427

55.0

   The cost is expensive for the 9-valent vaccines (Gardasil 9)

7566

64.8

   Difficulties to Access the 9-valent Vaccine ­Scalej, mean (SD)

9.9

2.1

Interpersonal level factors
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, TikTok, Red) in the past month
Testimonials given by others about HPV vaccination  Almost none

3975

34.0

  Seldom

4293

36.8

  Sometimes

2704

23.2

  Always706

6.0   Item score, mean (SD)k

2.0

0.9

Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines)  Almost none

3650

31.3

  Seldom

4778

40.9

  Sometimes

2726

23.3

  Always524

4.5   Item score, mean (SD)l

2.0

0.9

Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects)  Almost none

3971

34.0

  Seldom

4699

40.2

  Sometimes

2461

21.1

  Always547

4.7   Item score, mean (SD)m

2.0

0.9

Thoughtful consideration about veracity of information specific to HPV vaccines in the past month  Almost none

2551

21.8

  Seldom

3226

27.6

  Sometimes

4008

34.3

  Always

1893

16.3

   Item score, mean (SD)n

2.5

1.0

a

Consequences, item score: 0–10, a higher score indicated perceived severer consequences of HPV infectionbTimeline, item score: 0–10, a higher score indicated perceived HPV infection would last longercPersonal control, item score: 0–10, a higher score indicated the perception that one had stronger ability to control the HPV infectiondTreatment control, item score: 0–10, a higher score indicated the perception that the treatment had stronger ability to control the HPV infectione

Identity, item score: 0–10, a higher score indicated perceived more symptoms of HPV infectionfConcern, item score: 0–10, a higher score indicated one had more concern about HPV infectiong

Coherence, item score: 0–10, a higher score indicated one had more understanding about HPV infectionhEmotion, item score: 0–10, a higher score indicated one had more negative emotions caused by HPV infectioni
Satisfaction with Health Promotional Materials Scale, 3 items, scale score: 3–9, a higher score indicated more satisfaction with health promotional materials;
Cronbach’s alpha: 0.91; one factor was identified by exploratory factor analysis, explaining for 84.6% of total variancejDifficulties to Access 9-valent Vaccine Scale, 4 items, scale score: 4–12, a higher score indicated lower accessibility of the 9-valent vaccines; Cronbach’s alpha: 0.82; one
factor was identified by exploratory factor analysis, explaining for 52.7% of total variancek

Testimonials given by others about HPV vaccination, item score: 1–4, a higher score indicated a higher frequency of exposure to testimonials given by others about
HPV vaccinationl

Negative information about HPV vaccines, item score: 1–4, a higher score indicated a higher frequency of exposure to negative information about HPV vaccinesm

Negative information about other vaccine incidents in China, item score: 1–4, a higher score indicated a higher frequency of exposure to negative information aboutother vaccine incidents in ChinanThoughtful consideration about the veracity of information specific to HPV vaccines in the past month, item score: 1–4, a higher score indicated a higher frequencyof thoughtful consideration of the veracity of the information specific to HPV vaccines

Lin et al. BMC Medicine(2024) 22:328

Page 9 of 14

Table 3 Associations between background characteristics and HPV vaccine uptake among mothers
OR (95%CI)

P values

Age group, years
18–35

Reference

36–40

0.94 (0.85, 1.03)

0.15

41–52

0.56 (0.50, 0.62)<0.001

Education level
Junior high or below

Reference

Senior high or equivalent1.18 (1.06, 1.31)<0.001

College and above

1.80 (1.06, 1.31)

0.003

Relationship status
MarriedReference

Currently single

0.74 (0.61, 0.90)

0.002

Employment status
Full time

Reference

Without full-time job

0.85 (0.79, 0.91)<0.001Monthly household income, ¥ (US$)<5000 (685)

Reference

5000–9999 (685–1369)

1.28 (1.13, 1.43)<0.001

10,000–15,000 (1369–2054)

1.48 (1.29, 1.69)<0.001>15,000 (2054)

1.82 (1.61, 2.05)<0.001

Refuse to disclose

1.25 (1.08, 1.46)

0.004

Self-reported history of HPV infection
No

ReferenceYes

2.00 (1.66, 2.41)<0.001

Self-reported history of HPV-related diseases (i.e., genital warts, cervical/anus/vagina cancers, and precancerous lesions)
No

ReferenceYes

1.63 (1.27, 2.08)<0.001Age of the index daughter, years
9–12

Reference

13–17

0.84 (0.78, 0.91)<0.001

OR Crude odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants), CI Confidence intervalanchored. This study also examined the associations
between social media information exposure, satisfaction
with governmental health promotion materials, and HPV
vaccine uptake, which has not been extensively studied
among mothers in China. Other strengths of this study
included the large sample size (n = 11,678) and highresponse rate (83.8%).
In the study, 41.1% of the mothers received at least
one dose of HPV vaccination and 64.9% of vaccinatedmothers completed the whole course. The HPV vaccination uptake rate was higher than previous studies
targeting the same population conducted from 2020
to 2022 (2.6 to 18.6%) [23–25], which suggested anincrease in HPV vaccination coverage in this group.
However, the HPV vaccination uptake rate was still
lower than that of mothers having daughters in the
USA (49.0 to 83.0%) [62–64]. A modeling study suggested that HPV vaccination coverage should reach atleast 95% among females in China in order to effectively reduce HPV infection at the population level [65].
There is a strong need and large room to improve HPV
vaccination coverage among females in China.
In line with the findings of previous studies, mothers
who were older and single reported lower HPV vaccination uptake [50, 51, 66]. Since the rollout of the HPV
vaccination program started late in China (2016), older
mothers might perceive HPV vaccination as less effective for them [67, 68]. In China, single mothers often
have a heavy burden in raising their children, constrainedby tight financial resources [69, 70]. Lack of time andlow income might become barriers for single mothers
to receive HPV vaccination. In contrast, better socioeconomic status (higher education, higher income, andfull-time employment) was associated with higher HPV
vaccine uptake in this study. Such findings were similar

Lin et al. BMC Medicine(2024) 22:328

Page 10 of 14

Table 4 Associations of individual level and interpersonal level factors with HPV vaccine uptake among mothers
AOR (95%CI)

P values

Individual level factors
HPV vaccine refusal for the index daughters

0.82 (0.76, 0.89) <0.001

Domains of the Brief Illness Perception Questionnaire (B-IPQ), mean (SD)  Consequences

1.02 (1.00, 1.03) 0.01  Timeline

1.02 (1.00, 1.03) 0.01  Personal control

1.05 (1.04, 1.06) <0.001   Treatment control

1.04 (1.02, 1.05) <0.001

Identity

1.05 (1.03, 1.07) <0.001  Concern

1.14 (1.12, 1.15) <0.001  Coherence

1.13 (1.11, 1.15) <0.001  Emotions

1.06 (1.05, 1.07) <0.001   Satisfaction with Health Promotional Materials Scale

1.50 (1.46, 1.54) <0.001   Difficulties to Access the 9-valent Vaccine Scale

1.06 (1.04, 1.08) <0.001

Interpersonal level factors
Frequency of exposure to the following information on social media platforms (i.e., WeChat moments, Weibo, TikTok, Red) in the past month   Testimonials given by others about HPV vaccination

1.19 (1.14, 1.25) <0.001   Negative information about HPV vaccines (i.e., concerns about efficacies and supplies, side effects of the vaccines)

1.02 (0.98, 1.07) 0.38   Negative information about other vaccine incidents in China (i.e., selling problematic vaccines and severe side effects) 1.00 (0.96, 1.05) 0.93   Thoughtful consideration about veracity of information specific to HPV vaccines in the past month

1.11 (1.07, 1.16) <0.001

AOR Adjusted odds ratios, odds ratios obtained from two-level logistic regression models (level 1: schools, level 2: individual participants) after adjusting for significant
background characteristics listed in Table 3, CI Confidence interval

to previous studies [71, 72]. To address the disparities,
future HPV vaccination programs should pay more attention to single mothers and those with lower socioeconomic status. Furthermore, mothers who reported ahistory of HPV infection and HPV-related diseases had
higher vaccine uptake. It is possible that these mothers
perceive a greater threat from HPV and, therefore, have agreater motivation to get vaccinated [41].
Promoting HPV vaccination among mothers who havedaughters might increase vaccine coverage among bothmothers and their daughters, as higher HPV vaccination
uptake among mothers was correlated with lower vaccine
refusal for their daughters in this study. Our findings provided some practical implications to inform such healthpromotion. Our findings highlighted that HPV disease
perceptions could be incorporated into health communication messages to encourage vaccination uptake. Mothers who perceived more negative effects of HPV on theirlives (consequences), longer duration of HPV infection(timeline), and more severe symptoms if contracted HPV(identity) were more likely to receive HPV vaccination.
Health communication messages may anchor these perceptions by highlighting the effectiveness of HPV vaccination in preventing severe and long-term consequencesof HPV infection. Perceived higher personal control
and treatment control of HPV were also correlated withhigher HPV vaccination uptake. Similar associations havebeen observed in the context of seasonal influenza vaccination and hepatitis C virus testing [55, 73]. Beliefs inpersonal and treatment control may be linked to the perceived efficacy of HPV, a facilitator of vaccination uptake[41, 74]. Participants who better understood HPV (coherence) were more likely to be vaccinated. This is consistent
with previous studies among females that found betterknowledge of HPV was a facilitator of HPV vaccination
uptake [75]. HPV infection elicited negative emotions
and concerns among mothers. Similar to previous studies, such negative emotions and concerns were associatedwith higher HPV vaccination uptake [55, 73]. To promote
HPV vaccination, it may be beneficial to encourage theadoption of positive coping strategies that aim to alleviate the negative emotions and concerns associated with
HPV among mothers. It is plausible to encourage mothers experiencing high levels of negative emotions andconcerns to receive HPV vaccination, transforming their
negative emotions into prevention behaviors.
It is necessary to improve current HPV vaccination promotional materials, as less than half of the mothers foundsuch materials to help address their concerns and facilitate
their vaccination decisions. Higher satisfaction with these
health promotional materials was associated with higher
HPV vaccination uptake. Currently, most health promotional materials are developed by academics or healthcare professionals [76]. These materials are standardized

Lin et al. BMC Medicine(2024) 22:328

without considering the needs of end-users from their perspectives [77]. To address this issue, utilizing a co-creation
approach, which involves collaboration between academics, end-users, and other stakeholders, may help improvethese materials and lead to behavioral change [78, 79]. Thisapproach has shown promise in addressing complex issues
and promoting behavioral change [78].
About half of the mothers perceived some difficulties
in accessing the 9-valent HPV vaccines, including inadequate supply, limited quota, complicated procedures
to register, and high costs. It was interesting to find thatperceived more difficulties in accessing such vaccines
was associated with higher HPV vaccination uptake. One
possible explanation was that women would have firsthand experience of such difficulties when they were trying to get the 9-valent vaccines. In contrast, those who
did not have an interest in receiving the HPV vaccination
might be less aware of these issues. The 9-valent vaccines
developed and manufactured by China have enteredclinical trials with positive results [80]. The supply issues
might be tackled after the domestic 9-valent vaccines
enter the market. The Chinese government should also
consider simplifying the procedures for registering the
9-valent vaccines and expanding the basic health insurance to cover such vaccines to remove other difficulties
related to vaccine access.
Our study showed that HPV vaccination might not
be a hot topic on social media, as only one-third of theparticipants were sometimes/always exposed to information related to HPV vaccination in the past monththrough such channels. In line with previous studies [45,81], higher exposure to information related to HPV vaccination on social media was associated with higher HPV
vaccination uptake, highlighting the potential of usingsocial media for vaccination promotion. Health authorities should consider utilizing their official social media
platforms to disseminate health promotion messages
related to HPV vaccination, as Chinese mothers tend toperceive these accounts as credible sources of information [49]. Furthermore, our findings highlighted the roleof thoughtful consideration of the veracity of information
specific to HPV vaccination in improving vaccine uptake,which aligns with previous studies [49–51]. Thoughtful consideration may mitigate the negative impacts of
misinformation on the acceptance to receive HPV vaccination. Only 16.3% of the participants always thought
carefully about the veracity of information specific to
HPV vaccination, and there is room for improvement.
Health authorities should proactively identify misinformation related to HPV vaccination and provide timely
clarification. Empowering the women with adequate
skills to critically evaluate the veracity of information
may also be helpful.

Page 11 of 14

This study has several limitations. First, it is ideal tomeasure illness representations of main diseases causedby HPV (i.e., genital warts, cervical cancers, and other
HPV-related cancers) at the same time. However, wewere not able to do so due to the limited length of thequestionnaire. We followed the approach used by previous studies and focused on B-IPQ of HPV [82]. Second,
we did not include a group of mothers without daughtersin this study and were not able to ascertain whether thelevel of vaccination uptake and associated factors were
the same between mothers with and without daughters.
Third, all participants were recruited from Shenzhen,
and the findings cannot be generalized to other Chinese
cities. Shenzhen is one of the most developed cities in
China, and it has better access to and supply of HPV vaccines. The HPV vaccination uptake rate among femalesin Shenzhen is expected to be higher than that of lessdeveloped cities. Fourth, due to limited resources, wewere unable to verify the HPV vaccination status throughmedical records or laboratory testing. However, mothers were able to provide detailed information about theirvaccination. Mothers might over-report HPV vaccination uptake due to social desirability [83]. Fifth, the scalemeasuring difficulties in accessing the 9-valent vaccines
was self-constructed in the absence of validated measurement. Cronbach’s alpha on this scale was acceptable.
However, this scale was not validated by an independent
study. Furthermore, the survey was anonymous, and wewere unable to collect information from mothers who
refused to answer the questionnaire online. Selection bias
existed. Last but not least, this study was cross-sectionaland cannot establish causality.

Conclusions
In sum, the current HPV vaccination uptake rate among
mothers having daughters in Shenzhen, China, wassuboptimal. More efforts to promote HPV vaccination
uptake are needed, especially for single mothers andthose with low socioeconomic status. Modifying HPV
disease perceptions, improving governmental health promotion materials, and addressing difficulties in accessing
the 9-valent HPV vaccines might be useful in increasing
HPV vaccination uptake. Health authorities may consider
using social media as one communication channel toencourage HPV vaccination uptake.
Abbreviations
HPV	Human papillomavirus
B-IPQ	Brief Illness Perception Questionnaire
COVID-19	Coronavirus disease 2019SD	Standard deviation
OR	Crude odds ratio
AOR	Adjusted odds ratios
CI	Confidence interval
VIF	Variance inflation factor

Lin et al. BMC Medicine(2024) 22:328

Page 12 of 14

Acknowledgements
Not applicable.

5.

Authors’ contributions
Conceptualization: Z.L., S.C., L.S., Y.L., Z.W.; methodology: Z.L., S.C., L.S., Y.L.,
H.C., Z.H., Z.C., Y.F., X.L., Z.W.; data curation: Z.L., L.S., Y.L., H.C., Z.H., J.C., B.L., C.W.;
project administration: Z.L., L.S., Y.L., H.C., Z.H., J.C., B.L., C.W.; writing-originaldraft preparation: S.C., Z.L., L.S., Y.L., Z.C., Y.F., X.L., Z.W.; writing-review and editing: S.C., Z.C., Y.F., X.L., J.C., B.L., C.W, and Z.W. All authors read and approved thefinal manuscript.

6.

Funding
This study was funded by the Scientific Research Project of Medical and
Health Institutions in Longhua District [Grant number: 2021162] andthe Social Welfare Research Grant in Longhua District [Grant number:
2548A20210414BA70D4A].

8.

7.

9.

Availability of data and materials
No datasets were generated or analysed during the current study.

Declarations
Ethics approval and consent to participate
Prospective participants were informed that the survey was anonymous, theirinformation will be kept strictly confidential, and they had the right to refuse
to participate or withdraw from the study at any time. Refusal and withdrawal
would not affect their access to any services. Electronic informed consent was
obtained. Ethics approval was obtained from the Shenzhen Longhua District
Maternity and Child Healthcare Hospital (ref: 2022122201).
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1
Shenzhen Longhua District Maternity and Child Healthcare Hospital,
Shenzhen, China. 2 Centre for Health Behaviours Research, JC School of Public
Health and Primary Care, Faculty of Medicine, The Chinese University of Hong
Kong, Hong Kong SAR, China. 3 Shenzhen Futian District Maternity and Child
Healthcare Hospital, Shenzhen, China. 4 Center for Disease Control and Prevention, Shenzhen, China. 5 Department of Epidemiology and Infectious Disease
Control, Longhua Key Discipline of Public Health for the Prevention and Control of Infectious Diseases, Longhua Centre for Disease Control and Prevention,
Shenzhen, China. 6 Shenzhen Futian The Second People’s Hospital, Xinyidai
Industrial Park Social Health Station, Shenzhen, China. 7 Department of Healthand Physical Education, The Education University of Hong Kong, Hong Kong
SAR, China.
Received: 25 March 2024 Accepted: 22 July 2024

References
1. World Health Organization. Human papillomavirus and cancer, https://​www.​who.​int/​news-​room/​fact-​sheets/​detail/​human-​papil​loma-​virus-​
and-​cancer; 2024. Accessed 3 Jan 2024.
2. Cao W, Chen HD, Yu YW, Li N, Chen WQ. Changing profiles of cancer burden worldwide and in China: a secondary analysis of the global cancer
statistics 2020. Chin Med J (Engl). 2021;134(7):783–91. https://​doi.​org/​10.​1097/​cm9.​00000​00000​001474.
3. Wang H, Jiang Y, Wang Q, Lai Y, Holloway A. The status and challengesof HPV vaccine programme in China: an exploration of the related
policy obstacles. BMJ Glob Health. 2023;8(8). https://​doi.​org/​10.​1136/​
bmjgh-​2023-​012554.
4. Lu Y, Li P, Luo G, Liu D, Zou H. Cancer attributable to human papillomavirus infection in China: burden and trends. Cancer. 2020;126(16):3719–32.
https://​doi.​org/​10.​1002/​cncr.​32986.

10.

11.
12.
13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

Centers for Disease Control and Prevention. HPV vaccine safety andeffectiveness, https://​www.​cdc.​gov/​vacci​nes/​vpd/​hpv/​hcp/​safety-​effec​
tiven​ess.​html; 2023. Accessed 17 Oct 2023.
Robinson CL. Advisory Committee on Immunization Practices recommended immunization schedules for persons aged 0 through 18 years—
United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(4):86-7.
https://​doi.​org/​10.​15585/​mmwr.​mm650​4a4.
Ellingson MK, Sheikha H, Nyhan K, Oliveira CR, Niccolai LM. Human
papillomavirus vaccine effectiveness by age at vaccination: a systematic
review. Hum Vaccin Immunother. 2023;19(2):2239085. https://​doi.​org/​10.​
1080/​21645​515.​2023.​22390​85.
Datta S, Pink J, Medley GF, Petrou S, Staniszewska S, Underwood M, et al.
Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK. BMC Infect Dis. 2019;19(1):552. https://​doi.​
org/​10.​1186/​s12879-​019-​4108-y.
Choi HCW, Jit M, Leung GM, Tsui K-L, Wu JT. Simultaneously characterizing the comparative economics of routine female adolescentnonavalent human papillomavirus (HPV) vaccination and assortativityof sexual mixing in Hong Kong Chinese: a modeling analysis. BMC Med.
2018;16(1):127. https://​doi.​org/​10.​1186/​s12916-​018-​1118-3.
National Health Commission of the People’s Republic of China. Letter of
reply to proposal no. 2134 (medical and sports category no. 272), http://​www.​nhc.​gov.​cn/​wjw/​tia/​202101/​27e27​c66ed​65442​09a8a​eeede​12308​
80.​shtml; 2020. Accessed 4 Jan 2024.
Merck. Merck’s 9-valent HPV vaccine approved for women of age 9 to 45
years old, https://​www.​msdch​ina.​com.​cn/​compa​ny_​news_​2022-​08-​30;
2022. Accessed 20 Oct 2023.
Guo W, Wu Z, Qiu Y, Chen G, Zheng X. The timing of sexual debut among
Chinese youth. Int Perspect Sex Reprod Health. 2012;38(4):196–204.
https://​doi.​org/​10.​1363/​38196​12.
Li J, Li S, Yan H, Xu D, Xiao H, Cao Y, et al. Early sex initiation and subsequent unsafe sexual behaviors and sex-related risks among female
undergraduates in Wuhan China. Asia Pac J Public Health. 2015;27(2Suppl):21s–9s. https://​doi.​org/​10.​1177/​10105​39514​549186.
Lin Z, Liang X, Su L, Peng W, Chen H, Fang Y, et al. Coverage with the firstdose of human papillomavirus vaccination among females aged 9-50
years in Shenzhen, China: a surveillance based on administrative healthrecords in 2023. Vaccines, 2024;12(1). https://​doi.​org/​10.​3390/​vacci​nes12​
010075.
Wang Z, Wang J, Fang Y, Gross DL, Wong MCS, Wong ELY, et al. Parental
acceptability of HPV vaccination for boys and girls aged 9–13 years in
China - a population-based study. Vaccine. 2018;36(19):2657–65. https://​doi.​org/​10.​1016/j.​vacci​ne.​2018.​03.​057.
Ouma PO, van Eijk AM, Hamel MJ, Sikuku ES, Odhiambo FO, Munguti KM,
et al. Antenatal and delivery care in rural western Kenya: the effect oftraining health care workers to provide “focused antenatal care.” Reprod
Health. 2010;7:1. https://​doi.​org/​10.​1186/​1742-​4755-7-1.
Miller KS, Levin ML, Whitaker DJ, Xu X. Patterns of condom use among
adolescents: the impact of mother-adolescent communication. Am J
Public Health. 1998;88(10):1542–4. https://​doi.​org/​10.​2105/​ajph.​88.​10.​
1542.
Biederman E, Donahue K, Sturm L, Champion V, Zimet G. The association
between maternal human papillomavirus (HPV) experiences and HPV
vaccination of their children. Hum Vaccin Immunother. 2021;17(4):1000–
5. https://​doi.​org/​10.​1080/​21645​515.​2020.​18177​14.
Chao C, Slezak JM, Coleman KJ, Jacobsen SJ. Papanicolaou screening
behavior in mothers and human papillomavirus vaccine uptake in adolescent girls. Am J Public Health. 2009;99(6):1137–42. https://​doi.​org/​10.​2105/​ajph.​2008.​147876.
Berenson AB, Brown VG, Fuchs EL, Hirth JM, Chang M. Relationshipbetween maternal experiences and adolescent HPV vaccination. Hum
Vaccin Immunother. 2017;13(9):2150–4. https://​doi.​org/​10.​1080/​21645​
515.​2017.​13325​51.
Gray A, Fisher CB. Factors associated with HPV vaccine acceptability andhesitancy among Black mothers with young daughters in the UnitedStates. Front Public Health. 2023;11:1124206. https://​doi.​org/​10.​3389/​
fpubh.​2023.​11242​06.
Nguyen KH, Santibanez TA, Stokley S, Lindley MC, Fisher A, Kim D, et al.
Parental vaccine hesitancy and its association with adolescent HPV vaccination. Vaccine. 2021;39(17):2416–23. https://​doi.​org/​10.​1016/j.​vacci​ne.​2021.​03.​048.

Lin et al. BMC Medicine(2024) 22:328

23. Shi J, Yu W, Zheng H. Acceptability of human papillomavirus vaccine for
9–14 year-old girls among parents in four provinces of China. Beijing(China): Chinese Center for Disease Control and Prevention. 2020.
24. Yi Y, Xiu S, Shi N, Huang Y, Zhang S, Wang Q, et al. Perceptions and acceptability of HPV vaccination among parents of female adolescents 9–14 in
China: a cross-sectional survey based on the theory of planned behavior.
Hum Vaccin Immunother. 2023;19(2):2225994. https://​doi.​org/​10.​1080/​
21645​515.​2023.​22259​94.
25. Guo Q, Zhou W, Wen X, Lu J, Lu X, Lu Y. Discrepancy of human papillomavirus vaccine uptake and intent between girls 9–14 and theirmothers in a pilot region of Shanghai, China. Hum Vaccin Immunother.
2022;18(6):2132801. https://​doi.​org/​10.​1080/​21645​515.​2022.​21328​01.
26. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on
health promotion programs. Health Educ Q. 1988;15(4):351–77. https://​doi.​org/​10.​1177/​10901​98188​01500​401.
27. Ryan G, Avdic L, Daly E, Askelson N, Farris PE, Shannon J, et al.
Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders. Hum Vaccin
Immunother. 2021;17(4):1006–13. https://​doi.​org/​10.​1080/​21645​515.​
2020.​18392​90.
28. Maness SB, Thompson EL. Social determinants of human papillomavirus
vaccine uptake: an assessment of publicly available data. Public HealthRep. 2019;134(3):264–73. https://​doi.​org/​10.​1177/​00333​54919​838219.
29. Olaniyan A, Isiguzo C, Hawk M. The socioecological model as a framework
for exploring factors influencing childhood immunization uptake in
Lagos state, Nigeria. BMC Public Health. 2021;21(1):867. https://​doi.​org/​
10.​1186/​s12889-​021-​10922-6.
30. Sethi S, Poirier B, Canfell K, Smith M, Garvey G, Hedges J, et al. Working
towards a comprehensive understanding of HPV and cervical cancer
among Indigenous women: a qualitative systematic review. BMJ Open.
2021;11(6):e050113. https://​doi.​org/​10.​1136/​bmjop​en-​2021-​050113.
31. Adegboyega A, Adeyimika D, Omoadoni O, Mark D. HPV vaccination andcervical cancer screening promotion among Black individuals: social
ecological perspectives from key informants interviews. Ethn Health.
2023;28(7):1026–40. https://​doi.​org/​10.​1080/​13557​858.​2023.​21933​60.
32. Weinman J, Petrie KJ. Illness perceptions: a new paradigm for psychosomatics? J Psychosom Res. 1997;42(2):113–6. https://​doi.​org/​10.​1016/​
s0022-​3999(96)​00294-2.
33. Vollmann M, Salewski C. To get vaccinated, or not to get vaccinated, thatis the question: illness representations about COVID-19 and perceptions
about COVID-19 vaccination as predictors of COVID-19 vaccination
willingness among young adults in the Netherlands. Vaccines (Basel).
2021;9(9). https://​doi.​org/​10.​3390/​vacci​nes90​90941.
34. Nanteer-Oteng E, Kretchy IA, Nanteer DO, Kretchy JP, Osafo J. Hesitancy towards COVID-19 vaccination: the role of personality traits,
anti-vaccine attitudes and illness perception. PLOS Glob Public Health.
2022;2(12):e0001435. https://​doi.​org/​10.​1371/​journ​al.​pgph.​00014​35.
35. Wang Z, Fang Y, Dong W, Lau M, Mo PKH. Illness representations on
pneumonia and pneumococcal vaccination uptake among communityliving Chinese people with high-risk conditions aged ≥65 years — apopulation-based study. Hum Vaccin Immunother. 2021;17(5):1455–62.
https://​doi.​org/​10.​1080/​21645​515.​2020.​18146​53.
36. Moss-Morris R, Weinman J, Petrie K, Horne R, Cameron L, Buick D.
The revised illness perception questionnaire (IPQ-R). Psychol Health.
2002;17(1):1–16. https://​doi.​org/​10.​1080/​08870​44029​00014​94.
37. Chan DNS, Lee PPK, So WKW. Exploring the barriers and facilitators influencing human papillomavirus vaccination decisions among South Asianand Chinese mothers: a qualitative study. J Racial Ethn Health Disparities.
2023:1-13. https://​doi.​org/​10.​1007/​s40615-​023-​01623-4.
38. Wang Z, Fang Y, Yu FY, Chan PSF, Chen S. Governmental incentives,
satisfaction with health promotional materials, and COVID-19 vaccination uptake among community-dwelling older adults in Hong Kong: arandom telephone survey. Vaccines. 2022;10(5):732.
39. Wang Z, Fang Y, Yu FY, Chan PS, Chen S, Sun F. Facilitators and barriers totake up a COVID-19 vaccine booster dose among community-dwellingolder adults in Hong Kong: a population-based random telephonesurvey. Vaccines. 2022;10(6). https://​doi.​org/​10.​3390/​vacci​nes10​060966.
40. Yang DY, Bracken K. Update on the new 9-valent vaccine for humanpapillomavirus prevention. Can Fam Phys. 2016;62(5):399–402.
41. Shao X, Lu X, Zhou W, Huang W, Lu Y. HPV vaccination behavior, vaccine
preference, and health beliefs in Chinese female health care workers: aPage 13 of 14

42.

43.
44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.
55.

56.
57.

58.

nationwide cross-sectional study. Vaccines. 2023;11(8). https://​doi.​org/​10.​3390/​vacci​nes11​081367.
Xie P, Zhao J, Li X, Zou X, Liu G, Han X. Preference for human papillomavirus vaccine type and vaccination strategy among parents of school-age
girls in Guangdong province China. Prev Med Rep. 2023;36:102463.
https://​doi.​org/​10.​1016/j.​pmedr.​2023.​102463.
People’s daily online. Why is the nine-valent HPV vaccine hard to register?
2021. http://​socie​ty.​people.​com.​cn/​n1/​2021/​0820/​c1008-​32201​028.​html.
Accessed 1 March 2024.
National Healthcare Security Administration. Letter from the National
Healthcare Security Administration in response to proposal no. 2844
(proposal no. 152 in the medical and sports category) of the fourth
session of the Thirteenth National Committee of the Chinese People’s
Political Consultative Conference. 2021. https://​web.​archi​ve.​org/​web/​20220​12602​5918/​http:/​www.​nhsa.​gov.​cn/​art/​2021/​10/​26/​art_​110_​7263.​
html. Accessed 14 March 2024.
Ortiz RR, Smith A, Coyne-Beasley T. A systematic literature review to
examine the potential for social media to impact HPV vaccine uptake andawareness, knowledge, and attitudes about HPV and HPV vaccination.
Hum Vaccin Immunother. 2019;15(7–8):1465–75. https://​doi.​org/​10.​1080/​
21645​515.​2019.​15815​43.
Cascini F, Pantovic A, Al-Ajlouni YA, Failla G, Puleo V, Melnyk A, et al. Social
media and attitudes towards a COVID-19 vaccination: a systematic reviewof the literature. EClinicalMedicine. 2022;48:101454. https://​doi.​org/​10.​1016/j.​eclinm.​2022.​101454.
Kornides ML, Badlis S, Head KJ, Putt M, Cappella J, Gonzalez-Hernadez
G. Exploring content of misinformation about HPV vaccine on Twitter. J Behav Med. 2023;46(1–2):239–52. https://​doi.​org/​10.​1007/​
s10865-​022-​00342-1.
Muric G, Wu Y, Ferrara E. COVID-19 vaccine hesitancy on social media:
building a public Twitter data set of antivaccine content, vaccine misinformation, and conspiracies. JMIR Public Health Surveill.
2021;7(11):e30642. https://​doi.​org/​10.​2196/​30642.
Pan Y, Xin M, Zhang C, Dong W, Fang Y, Wu W, et al. Associations of mental
health and personal preventive measure compliance with exposure to
COVID-19 information during work resumption following the COVID19 outbreak in China: cross-sectional survey study. J Med Internet Res.
2020;22(10):e22596. https://​doi.​org/​10.​2196/​22596.
Zhang K, Fang Y, Chan PS, Cao H, Chen H, Hu T, et al. Behavioral intention
to get a booster dose of COVID-19 vaccine among Chinese factory workers. Int J Environ Res Public Health. 2022;19(9). https://​doi.​org/​10.​3390/​
ijerp​h1909​5245.
Singh A, Lai AHY, Wang J, Asim S, Chan PS, Wang Z, et al. Multilevel
determinants of COVID-19 vaccine uptake among South Asian ethnic
minorities in Hong Kong: cross-sectional web-based survey. JMIR Public
Health Surveill. 2021;7(11):e31707. https://​doi.​org/​10.​2196/​31707.
Lin Z, Chen S, Su L, Chen H, Fang Y, Liang X, et al. Exploring motherdaughter communication and social media influence on HPV vaccine
refusal for daughters aged 9–17 years in a cross-sectional survey of
11,728 mothers in China. Hum Vaccin Immunother. 2024;20(1):2333111.
https://​doi.​org/​10.​1080/​21645​515.​2024.​23331​11.
Wollebæk D, Fladmoe A, Steen-Johnsen K, Ihlen Ø. Right-wing ideological constraint and vaccine refusal: the case of the COVID-19 vaccine in
Norway. Scan Polit Stud. 2022;45(2):253–78. https://​doi.​org/​10.​1111/​
1467-​9477.​12224.
Broadbent E, Petrie KJ, Main J, Weinman J. The brief illness perception
questionnaire. J Psychosom Res. 2006;60(6):631–7. https://​doi.​org/​10.​1016/j.​jpsyc​hores.​2005.​10.​020.
Wang Z, Mo PKH, Fang Y, Ip M, Lau JTF. Factors predicting first-time
hepatitis C virus testing uptake among men who have sex with men
in China: an observational prospective cohort study. Sex Transm Infect.
2020;96(4):258–64. https://​doi.​org/​10.​1136/​sextr​ans-​2019-​054248.
Zhang K, Fang Y, Chan PSF, Cao H, Chen H, Hu T, et al. Behavioral intention
to get a booster dose of COVID-19 vaccine among Chinese factory workers. Int J Environ Res Public Health. 2022;19(9):5245.
Zhang K, Liang X, Tam KLW, Kawuki J, Chan PS, Chen S, et al. Changes in
COVID-19 vaccine acceptability among parents with children aged 6-35
months in China-repeated cross-sectional surveys in 2020 and 2021. Vaccines. 2023;11(1). https://​doi.​org/​10.​3390/​vacci​nes11​010170.
Pan Y, Fang Y, Xin M, Dong W, Zhou L, Hou Q, et al. Self-reported compliance with personal preventive measures among Chinese factory workers

Lin et al. BMC Medicine

59.

60.

61.
62.

63.

64.
65.

66.

67.

68.

69.
70.
71.

72.

73.
74.

75.

76.

(2024) 22:328

at the beginning of work resumption following the COVID-19 outbreak:cross-sectional survey study. J Med Internet Res. 2020;22(9):e22457.
https://​doi.​org/​10.​2196/​22457.
Zhang KC, Fang Y, Cao H, Chen H, Hu T, Chen Y, et al. Behavioral intention
to receive a COVID-19 vaccination among Chinese factory workers: crosssectional online survey. J Med Internet Res. 2021;23(3):e24673. https://​doi.​org/​10.​2196/​24673.
Patel MS, Niemann CU, Sally MB, De La Cruz S, Zatarain J, Ewing T, et al.
The impact of hydroxyethyl starch use in deceased organ donors on thedevelopment of delayed graft function in kidney transplant recipients: apropensity-adjusted analysis. Am J Transplant. 2015;15(8):2152–8. https://​doi.​org/​10.​1111/​ajt.​13263.
Paul P, Pennell ML, Lemeshow S. Standardizing the power of the
Hosmer-Lemeshow goodness of fit test in large data sets. Stat Med.
2013;32(1):67–80. https://​doi.​org/​10.​1002/​sim.​5525.
Srivastava T, Head KJ, O’Dell SM, Feemster KA, Panozzo CA, Zimet GD,
et al. Characterizing U.S. mothers with high human papillomavirus vaccine intent yet unvaccinated adolescents. Prev Med. 2023;169:107472.
https://​doi.​org/​10.​1016/j.​ypmed.​2023.​107472.
Kornides M, Head KJ, Feemster K, Zimet GD, Panozzo CA. Associations
between HPV vaccination among women and their 11–14-year-old children. Hum Vaccin Immunother. 2019;15(7–8):1824–30. https://​doi.​org/​10.​
1080/​21645​515.​2019.​16256​42.
Roberts ME, Gerrard M, Reimer R, Gibbons FX. Mother-daughter communication and human papillomavirus vaccine uptake by college students.
Pediatrics. 2010;125(5):982–9. https://​doi.​org/​10.​1542/​peds.​2009-​2888.
Xia C, Hu S, Xu X, Zhao X, Qiao Y, Broutet N, et al. Projections up to 2100
and a budget optimisation strategy towards cervical cancer eliminationin China: a modelling study. Lancet Public Health. 2019;4(9):e462–72.
https://​doi.​org/​10.​1016/​s2468-​2667(19)​30162-8.
Adekanmbi V, Guo F, Hsu CD, Shan Y, Kuo YF, Berenson AB. Incomplete
HPV vaccination among individuals aged 27-45 years in the UnitedStates: a mixed-effect analysis of individual and contextual factors. Vaccines. 2023;11(4). https://​doi.​org/​10.​3390/​vacci​nes11​040820.
Chesson HW, Meites E, Ekwueme DU, Saraiya M, Markowitz LE. Costeffectiveness of HPV vaccination for adults through age 45 years in the
United States: estimates from a simplified transmission model. Vaccine.
2020;38(50):8032–9. https://​doi.​org/​10.​1016/j.​vacci​ne.​2020.​10.​019.
Kim JJ, Simms KT, Killen J, Smith MA, Burger EA, Sy S, et al. Human papillomavirus vaccination for adults aged 30 to 45 years in the United States:
a cost-effectiveness analysis. PLoS Med. 2021;18(3):e1003534. https://​doi.​
org/​10.​1371/​journ​al.​pmed.​10035​34.
Li Q. Mothers left without a man: poverty and single parenthood in
China. Soc Incl. 2020;8(2):114–22.
Zhao X, Basnyat I. Gendered social practices in reproductive health: aqualitative study exploring lived experiences of unwed single mothers in
China. Sociol Health Illn. 2021;43(5):1237–53.
de Munter AC, Klooster TMS-VT, van Lier A, Akkermans R, de Melker HE,
Ruijs WLM. Determinants of HPV-vaccination uptake and subgroups witha lower uptake in the Netherlands. BMC Public Health. 2021;21(1):1848.
https://​doi.​org/​10.​1186/​s12889-​021-​11897-0.
Grandahl M, Larsson M, Dalianis T, Stenhammar C, Tydén T, WesterlingR, et al. Catch-up HPV vaccination status of adolescents in relation tosocioeconomic factors, individual beliefs and sexual behaviour. PLoS One.
2017;12(11):e0187193. https://​doi.​org/​10.​1371/​journ​al.​pone.​01871​93.
Mo PK, Lau JT. Illness representation on H1N1 influenza and preventive behaviors in the Hong Kong general population. J Health Psychol.
2015;20(12):1523–33. https://​doi.​org/​10.​1177/​13591​05313​516031.
Alsulami FT, Sanchez J, Rabionet SE, Popovici I, Baraka MA. Predictor of
HPV vaccination uptake among foreign-born college students in the U.S.:
an exploration of the role of acculturation and the health belief model.
Vaccines. 2023;11(2). https://​doi.​org/​10.​3390/​vacci​nes11​020422.
Netfa F, King C, Davies C, Rashid H, Tashani M, Booy R, et al. Perceived
facilitators and barriers to the uptake of the human papillomavirus(HPV) vaccine among adolescents of Arabic-speaking mothers in NSW,
Australia: a qualitative study. Vaccine: X. 2023;14:100335. https://​doi.​org/​
10.​1016/j.​jvacx.​2023.​100335.
Blevins D, Farmer MS, Edlund C, Sullivan G, Kirchner JE. Collaborative
research between clinicians and researchers: a multiple case study of
implementation. Implement Sci. 2010;5:76. https://​doi.​org/​10.​1186/​
1748-​5908-5-​76.

Page 14 of 14

77. Finegood DT, Johnston LM, Steinberg M, Matteson CL, Deck PB. Complexity, systems thinking, and health behavior change. In: S Kahan, AC Gielen,
PJ Fagan, LW Green, eds. Health behavior change in populations. UnitedStates: Johns Hopkins University Press; 2014. p. 435–8. https://​doi.​org/​10.​
56021/​97814​21414​553.
78. Leask CF, Sandlund M, Skelton DA, Altenburg TM, Cardon G, Chinapaw
MJM, et al. Framework, principles and recommendations for utilisingparticipatory methodologies in the co-creation and evaluation of publichealth interventions. Res Involv Engagem. 2019;5:2. https://​doi.​org/​10.​
1186/​s40900-​018-​0136-9.
79. Galvagno M, Dalli D. Theory of value co-creation: a systematic literature
review. Manag Serv Qual. 2014;24(6):643–83.
80. Recbio. Recbio announces phase III clinical trial progress of recombinant
HPV 9-valent vaccine. 2024. https://​www.​recbio.​cn/​en/​media/​press-​relea​
se/​recbio-​annou​nces-​phase-​iii-​clini​cal-​trial-​progr​ess-​of-​recom​binant-​
hpv-9-​valent-​vacci​ne/. Accessed 2 March 2024.
81. Thompson EL, Preston SM, Francis JKR, Rodriguez SA, Pruitt SL, Blackwell
JM, et al. Social media perceptions and internet verification skills associated with human papillomavirus vaccine decision-making among
parents of children and adolescents: cross-sectional survey. JMIR Pediatr
Parent. 2022;5(3):e38297. https://​doi.​org/​10.​2196/​38297.
82. McBride E, Marlow LAV, Chilcot J, Moss-Morris R, Waller J. Distinct illness
representation profiles are associated with anxiety in women testing
positive for human papillomavirus. Ann Behav Med. 2022;56(1):78–88.
https://​doi.​org/​10.​1093/​abm/​kaab0​22.
83. Waller J, Marlow LA, Wardle J. The association between knowledgeof HPV and feelings of stigma, shame and anxiety. Sex Transm Infect.
2007;83(2):155–9. https://​doi.​org/​10.​1136/​sti.​2006.​023333.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.